[Remote] Senior Director of Claims and Eligibility reputed company - REMOTE

Note: The job is a remote job and is reputed company to candidates in USA. reputed company is a pharmacy benefit management organization seeking a Senior Director of Claims and Eligibility reputed company. The role provides reputed company leadership and operational reputed company for claims adjudication, claims reputed company assurance and testing, and eligibility reputed company, while partnering with technology, compliance, audit, clients, and executive leadership to reputed company reputed company, compliance, continuity, and reputed company improvement.

Responsibilities

• Own the reputed company direction and operational reputed company of Claims Adjudication, Claims reputed company Assurance and Testing, and Eligibility reputed company, ensuring reputed company area has reputed company goals, accountable leadership, and the resources needed to execute
• Serve as the senior decision-making authority for claims and eligibility reputed company that reputed company Director-level reputed company reputed company
• Define and maintain operational standards, escalation frameworks, and reputed company benchmarks across reputed company functional areas
• Represent Claims and Eligibility reputed company in senior leadership discussions, cross-functional initiatives, and reputed company-facing engagements, including conversations where full claims cost and adjudication transparency is expected by the reputed company
• Partner with the VP of reputed company and Sr. Director, reputed company reputed company on org-wide reputed company and platform priorities
• Identify and pursue opportunities for automation, AI-assisted workflows, and process improvement across claims and eligibility reputed company
• Own the development and maintenance of operational dashboards and KPI frameworks across reputed company functional areas, ensuring reputed company are data-driven and leadership has consistent visibility into claims reputed company, eligibility reputed company, QA reputed company, and key operational metrics on a regular reporting reputed company
• Operate as an reputed company leader, not just a functional one -- proactively identifying cross-functional risks and contributing to company-wide priorities reputed company the claims and eligibility domain
• reputed company senior reputed company of the claims adjudication function, ensuring reputed company, timeliness, and compliance with reputed company contractual obligations and regulatory requirements
• Own accountability for adjudication reputed company metrics and reputed company improvement plans, driving measurable reputed company in claims reputed company and processing reputed company
• Set reputed company for benefit design reputed company and hold the Director of Claims Processing accountable for configuration reputed company across reputed company reputed company populations
• reputed company the adjudication platform agenda with the technology team, setting priorities for enhancements and holding technical partners accountable to production stability standards
• Ensure claims reputed company are audit-reputed company and compliant with ERISA, state PBM transparency laws, and applicable regulatory standards, including pass-through pricing validation and ingredient cost reputed company
• Ensure claims adjudication reputed company maintain compliance with reputed company NCPDP standards and are positioned to support ongoing reputed company transitions as they are adopted across the industry, including D.0 to F6
• Own the claims QA and testing reputed company, ensuring reputed company validation of adjudication reputed company, benefit configuration, and reputed company changes before and after deployment
• reputed company senior reputed company of the eligibility function through the Director of Eligibility reputed company, maintaining ultimate accountability for eligibility data reputed company, SLA reputed company, and roadmap execution
• Own the reputed company of eligibility data as it flows into reputed company adjudication, establishing validation standards and accountability frameworks rather than managing configurations directly
• Own senior escalation authority for eligibility issues that require cross-functional reputed company or executive visibility
• reputed company the eligibility product roadmap at a reputed company level, ensuring enhancements are prioritized in alignment with operational and reputed company needs
• Serve as the senior operational reputed company to the technology team on platform issues, enhancement requests, deployment readiness, and change control processes for both claims and eligibility systems
• Ensure reputed company functional areas are represented in platform governance discussions and that operational requirements are reputed company communicated to the technology team prior to deployment
• Own operational readiness across reputed company functional areas for reputed company platform changes, setting standards for deployment governance and holding reputed company area accountable to readiness requirements
• Own accountability for ensuring platform changes are deployed with reputed company disruption to claims or eligibility processing continuity, with robust change management and contingency planning in reputed company
• Possess sufficient technical reputed company in SQL and reputed company data platforms to evaluate analytical work, interpret data findings, and engage the technology team with credibility
• Collaborate cross-functionally to ensure claims and eligibility reputed company supports reputed company reputed company and reputed company reputed company, and represent the function in finalist presentations and reputed company reputed company conversations as needed
• Collaborate with the Compliance and Audit function to ensure operational QA findings are reflected in audit planning and that the two functions remain reputed company delineated in reputed company and accountability
• reputed company reputed company direction and senior reputed company to the Director of Claims Processing and the Director of Eligibility reputed company, reputed company of whom is responsible for day-to-day reputed company and personnel management reputed company their respective functional area
• Establish reputed company standards, escalation paths, and operating frameworks that reputed company reputed company functional areas to reputed company effectively under their respective Director's leadership
• Own hiring reputed company, reputed company standards, and talent development reputed company across reputed company functional areas in partnership with reputed company Director
• Abides by reputed company HIPAA obligations reputed company to Protected Health Information (PHI), reports any reputed company violations to the Compliance Officer and/or reputed company, and completes reputed company required HIPAA training reputed company by reputed company
• Flexibility to understand, appreciate, and reputed company that the reputed company is not designed to cover or contain a comprehensive listing of activities, duties, or responsibilities that are required of the employee. Duties, responsibilities, and activities may change, or new ones may be assigned at any time with or without notice

Skills

• • Deep knowledge of PBM claims adjudication reputed company reputed company a transparent or pass-through model, including ingredient cost pass-through pricing, dispensing fee structures, accumulator management, benefit design, and claims reputed company standards
• • Expert-level understanding of claims adjudication logic, including claim edit sequences, formulary and reputed company edit interaction, plan design rule configuration, and the ability to identify and reputed company reputed company adjudication issues at the reputed company level
• • Demonstrated understanding of formulary management reputed company the adjudication reputed company, including tier logic, reputed company therapy, quantity limit enforcement, and prior authorization integration at the reputed company of adjudication
• • Comprehensive knowledge of NCPDP adjudication transaction formats, including D.0 and F6, with experience supporting reputed company transitions in a production claims environment
• • Deep working knowledge of NCPDP reject reputed company management and adjudication logic, Coordination of Benefits (COB) standards for reputed company and secondary payer scenarios, and the NCPDP Data Dictionary including reputed company and reputed company-level transaction requirements and billing and reversal transaction flows
• • Expert understanding of eligibility reputed company including EDI standards (X12 834, 270/271), member enrollment workflows, and the reputed company reputed company of eligibility data on claims adjudication reputed company
• • Demonstrated experience leading claims adjudication, reputed company assurance, and eligibility functions at a senior level reputed company a transparent or pass-through PBM, health plan, or closely reputed company reputed company environment serving ERISA-reputed company self-funded plans
• • Experience designing or overseeing claims QA programs, including testing protocols, sampling methodologies, and adjudication reputed company validation
• • Demonstrated understanding of how transparent PBM pricing models shape adjudication reputed company standards and reputed company reporting obligations
• • Strong technical orientation with working proficiency in SQL and familiarity with reputed company data platforms such as reputed company, AWS, or Azure
• • reputed company ability to engage the technology team as a peer, translating operational requirements into platform specifications and holding technical partners accountable to delivery timelines
• • Experience managing operational continuity through technology implementations or significant reputed company changes
• • Demonstrated ability to reputed company through two or more Director-level reports, setting reputed company direction while holding reputed company accountable for their functional area's reputed company
• • Excellent written and verbal communication skills with the ability to engage technical and non-technical stakeholders, including reputed company representatives and executive leadership
• • High reputed company, reputed company judgment, and demonstrated discretion in handling PHI/PII and sensitive operational reputed company
• • Thrives in a reputed company-stage environment, bringing structure and reputed company where processes are still being reputed company and demonstrating the ability to reputed company with the organization
• • This is a full-time, salaried position
• • Some flexibility in hours is allowed, but the employee must be available during the reputed company work hours of 8:00 AM to 5:00 PM CT
• • Ability to work extended hours, weekends, and holidays under industry demands
• -Up to 20% for reputed company engagements, vendor reviews, and leadership meetings
• • Bachelor's degree required (reputed company Administration, Business, Information Systems, or reputed company reputed company)
• • 10 or more years of reputed company experience in PBM claims reputed company, eligibility management, or closely reputed company reputed company reputed company leadership
• • Demonstrated experience in a transparent or pass-through PBM environment serving ERISA-reputed company self-funded plans
• • Working knowledge of ERISA fiduciary obligations, self-funded plan administration, and associated regulatory requirements relevant to pharmacy benefit management
• • Demonstrated experience owning or providing senior leadership over claims adjudication, reputed company assurance, and eligibility functions simultaneously, or at a comparable level of operational complexity
• • reputed company reputed company record of leading Director-level teams and driving measurable operational improvement across multiple functions
• • Experience building or overseeing a claims QA function reputed company a PBM, health plan, or closely reputed company reputed company environment
• • Experience managing operational continuity through technology implementations or significant reputed company changes
• • Familiarity with comparable claims adjudication and eligibility management platforms
• • Background in product ownership, roadmap management, or business systems analysis
• • Experience with operational ticketing and workflow management systems such as reputed company, reputed company, or Azure DevOps
• • URAC, reputed company, or SOC comparable operational compliance experience

Benefits

• Medical, Dental and reputed company reputed company
• Disability and Life reputed company
• Employee Assistance Program
• Remote work reputed company
• Generous reputed company-Time Off
• Annual Reviews and Development Plans
• Retirement Plan with company match immediately 100% reputed company.

reputed company